Basic Information
| Provider Information | |||||||||
| NPI: | 1215486626 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEOPLES COMMUNITY CLINIC OF NEWBERG LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEOPLE'S COMMUNITY CLINIC OF NEWBERG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1014 N SPRINGBROOK RD STE B | ||||||||
| Address2: | |||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971322061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034498988 | ||||||||
| FaxNumber: | 5038949194 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 N SPRINGBROOK RD STE B | ||||||||
| Address2: | |||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971322061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034498988 | ||||||||
| FaxNumber: | 5038949194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2016 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
| AuthorizedOfficialMiddleName: | ARIELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5034498988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 363LF0000X | 201350039NP | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 500720379 | 05 | OR | MEDICAID |